Scott and Emma Peters: Both were naturally conceived, but Emma followed a nearly decade-long bout of secondary infertility.

Drake Shigemura: Mother Dot had five ectopic pregnancies before he was the product of her ninth in-vitro attempt.

Schuyler Shigemura: Was conceived naturally after two ectopic pregnancies and after two failed in-vitro attempts

Emma and Ethan Dwyer: Conceived using a donor-egg cycle Infertility

Noah Chun: A "miracle baby" conceived using a single embryo for in-vitro fertilization

Amalya Sales: Conceived using in-vitro fertilization

FACTS

Infertility is a disease of the reproductive system, defined as the inability to conceive after a couple has had one year of unprotected, well-timed intercourse, or if the woman has suffered from multiple miscarriages.

Infertility occurs in 10 percent of the reproductive-age population, or one in six couples (more than 6 million U.S. residents). In Hawai'i, that's about 23,000 couples.

With fertility treatments on the rise in America  about 4 million people sought help a decade ago; today, it's about 6 million  new techniques in baby-making are rapidly coming to the fore, as science rushes ahead to help propagate the species.

Fraternal twins born five years apart. Picking a boy embryo instead of a girl. Women in their 50s and 60s becoming mothers with donor eggs.

These issues didn't come up in what were the early days of fertility treatments, but they're here, now.

At one point, Dot Shigemura thought she wouldn't be among the propagators. After five ectopic pregnancies and nine attempts at in-vitro fertilization, however, she is mother to two sons, the naturally conceived Schuyler, 9, and in-vitro baby Drake, who turned 3 just last week.

As a result of her experience, Shigemura talks about her frustration at being on the other side of the divide from "the fertile community," just as the deaf try to relate to the "the hearing community."

"It feels devastating; it feels isolating," said Shigemura, who went on to co-found Resolve of Hawai'i in 1993. "Everybody else can get pregnant, do this natural function, and you can't. The repeated failed attempts start to really wear on your self-esteem. Your friends are talking about their babies, and you have no idea what any of that language means, because you're just not a parent (even though you want to be)."

Resolve of Hawai'i, a 150-member support organization, has helped more than 700 people cope with the array of choices available to the "infertile community."

And thanks to science, the choices today are staggering.

There are drug therapies that help women ovulate not just an extra egg or two, but a baker's dozen. Those eggs can be fertilized by sperm that has gone through the "wash," a process for men with low sperm count that filters out the weakest or abnormal sperm.

In special cases where only a single sperm can be used, that sperm is injected into an egg by micro-manipulation to create an embryo outside the uterus.

Then, also outside a uterus, the embryos can be grown to the blastocyst stage, an approximately 64-cell organism, in the laboratory before transfer into the womb.

This is a huge breakthrough: Before, embryos could only survive in a lab for up to three or four days, creating a four- to six-cell embryo. New incubator technology and advanced lab techniques make it possible to keep embryos in a laboratory incubator for up to five days. The benefit is creating embryos that show the strongest chance of surviving, which reduces the number needed for implantation and cuts down on multiple births.

After administering medications to prepare the uterus lining, one or two blastocysts can be implanted.

Success rates increasing

Dr. Philip McNamee, director of Pacific In Vitro Fertilization Institute, said more than 1,300 in-vitro babies have been born since the 1985 birth of Jacquelyn Low.

At 17, Low now calls herself "Jacqui." The Iolani senior says she "knew myself as a test-tube baby since back in fifth grade, but I didn't know what that meant ... I didn't see myself as a miracle. I thought it was just science."

Fifteen years ago, in-vitro fertilization rarely was an option for women older than 35; success was rare, either because they didn't produce as many mature eggs or the embryo transfers didn't "take." Opening up the options for older mothers are egg-donor programs and something called "assisted hatching." The first uses eggs from a younger woman; the second helps embryos to break out of their shells, which they need to do to implant into the womb, said Dr. Tom Huang, another Honolulu fertility expert.

So you've undergone all these procedures and created an heir and a spare for implantation, as well as numerous siblings. Couples whose in-vitro fertilization cycles generate a large number of embryos can have the extra embryos frozen for later.

Huang talks about one Kona couple, now on the Mainland, who used a cycle of embryos to have their first baby, then went back and had two sets of twins on two successive frozen cycles.

"She has a full family, five kids from different pregnancies, conceived at the same time but differing in age by about five years," he said. "In a sense, you have quintuplets, but you have them over a period of time."

The family holds a special place in Huang's heart, and not only because he had a hand  literally  in their conception.

He went to Kona about five years ago to baby-sit, giving the parents an afternoon off, and remembers the instant all five kids looked at him.

"I have to say, it was a special moment for me. You're just sitting in the presence of ... " Huang's voice starts to trail off, but eventually he recovers himself. "It was just a magical moment."

This, he said, is why he does what he does, but then he laughed. "If I had to baby-sit every weekend, I'd be a little tired, but it was a magical moment. There was a lot of love in that room."

With all this science comes questions.

Most use anonymous donors

Oprah Winfrey recently did a show on youth who tracked down their sperm-donor biological fathers, focusing on their yearning to know more about their genetic makeup than the DNA strands.

Jacqui Low says she has fewer questions than her adopted friends do: "I had a regular childhood. My father is my father, my mother is my mother  it was my mother's egg and father's sperm. The only difference is in how I was conceived."

Even though, in a fit of pique, her mother Janice might say the eggs got switched, Jacqui giggles and says she knows she's loved.

"It's fun table talk," she said. "My chemistry teacher said the only difference is your parents may have actually wanted you.

"I see no psychological problems attached to being a test-tube baby, except that you might want to be perfect, because you knew your parents really wanted you."

In the case of donor eggs and sperm, most  95 percent to 98 percent  of Pacific In Vitro's clients use anonymous donors, said Huang, though one couple profiled used a "directed donor." A few elect to have a known donor, such as a family member, contribute the needed gamete to the process, he said.

Donors expect confidentiality, said Huang. "The sperm bank or egg donor entity usually has legal contracts to keep confidentiality intact."

In fact, records of donors often are not kept beyond a certain period  though that raises issues the industry is just beginning to address, such as what to do when a genetic disease manifests later. Is it possible, for example, to alert an egg-donor recipient to her increased chances of getting breast cancer, if it shows up in the donor later? Can such information be passed on without disturbing anonymity?

"The legal framework would have to be addressed," Huang said.

Pacific Connection Fertility Services provides anonymous egg donors to Pacific In Vitro. Founder Anne Rust said most of Pacific Connection's donors are college students, "young women (whose futures) are not set yet," and do not want their identities revealed. "Some agencies on the Mainland say they will keep track, but in 15 to 18 years, how do you keep track of these young women?" Rust asked.

Rust said she carefully screens donors to make sure they don't have an attachment to the future product.

"(These young women) really believe they're making a difference," Rust said. "The reason they want to be anonymous is because they see this the same as giving blood."

Almost none of the 50 donors in her present pool do it for the money  though the $3,500 will help pay for tuition and books, said Rust, who advertises through the University of Hawai'i for potential donors.

"You are donating your eggs," she said, with the emphasis on "donating." "Compensation is for time, potential discomfort and potential risk you're taking."

Obtaining eggs takes awhile

Rust acknowledges that so far, egg donation evokes different feelings than sperm donation, though she questions the logic of it.

"Sperm donation's been around since beginning of time," she said. "You'd have Joe Farmer coming in to impregnate (a neighbor's) wife. So, many children are not the biological children of (the father they know), but there's never been a huge discussion of this."

For one, sperm can be obtained in a few minutes. The procedure for obtaining human eggs requires six weeks of treatment, plus the actual extraction using an ultrasound probe and long metal needles.

Still, he said, "The great thing about using an egg donor, as long as the couple is able to accept that route, is that 70 percent of the time you can get pregnancies. It's been a great advance for people who've had only a 5 (percent) to 10 percent chance. It's been a real breakthrough."

He also counsels couples to consider in-vitro fertilization, which can cost about the same as an adoption.

Hawai'i an in-vitro pioneer

While fertility treatments are not cheap  a single in-vitro attempt can cost $10,000  in Hawai'i, at least, it's not a question of the haves vs. the have-nots.

In 1987, Hawai'i became the first state to require that insurance carriers cover a single in-vitro fertilization attempt. Now, 13 other states have in-vitro fertilization requirements on their books, said McNamee, a past president of the Society for Assisted Reproductive Technology, a national oversight group that sets standards for in-vitro fertilization.

But as Hawai'i enters the next phase of fertility advances, society has a long way to go to catch up with science, especially when breakthroughs in genetic testing can now help identify embryos for implantation. Yes, this is a girl and this is a boy. Would you like one of each, or two of the other?

Those are questions for moralists, but the biological drive to procreate is one McNamee can recognize.

"There's no question that ethicists and clergy and people who write the laws probably have not been faced with this personally," said McNamee. "Unless you have this facing you personally, you don't have insight into the sadness and way women feel about wanting to have a baby. It's a powerful, driving force. It can cause strife from in-laws, parents wanting a grandchild, and the pressure of peers having children. It can cause psychological problems, and a lot of human misery."

Happy ending: Now have twins, Ethan and Emma, 5 months old, as well as Christopher, 4, adopted.

Linda Dwyer of Palolo gets a quiet and faraway look when she remembers March 5, 1999.

That was the day of her first failed adoption.

"It was much worse than a failed in-vitro," said Dwyer, a pediatric nurse for Kaiser.

A young mother in Minnesota was pregnant with twin girls. Through a private adoption company, the Dwyers had sent her $25,000. Toward the end of the pregnancy, Linda would call every day. She even had named the girls.

A week before the girls were due, Linda made her daily phone call to Minnesota. The woman hung up on her  she had decided she couldn't go through with the adoption.

Linda was devastated. She has tried these past years to forgive and move on.

Later that year, they did adopt a son, Christopher, 4, through a friend of a friend.

Being in the pediatrics field, she had yearned to be pregnant.

"I always wanted the experience," she said.

Now married for 14 years, Linda, 42, had several failed in-vitro attempts. When she and her husband moved from California to Hawai'i, they decided to try once more. Linda learned her supplemental insurance policy would cover an in-vitro fertilization, and using an egg donor, they became the parents of twins Ethan and Emma, now 5 months old.

Even though she had been in excellent physical shape, the pregnancy put her down for five months' bed rest.

"I've never seen anything wrong" with in-vitro fertilization, said Linda, who said she is a Christian. "God gave us this much love to share. Mom and dad is a verb, not a noun."

Note: They had originally delayed their procedure for a year to sort out religious conflicts.

Mike Chun, a contractor, met his wife, Pam, a teacher at Salt Lake Elementary, when both were in their 30s.

They met, fell in love, married and planned to have kids. Maybe three, if Mike had his way. You see, both were from big Catholic families  a big 'ohana was their cultural and family tradition.

But years went by without a pregnancy. Pam talked to colleagues at work who also struggled with infertility. They pointed her to fertility specialists.

She had a laparoscopy, which involves putting a miniature lighted telescope-like tool and other instruments into the abdomen to dilate her narrow fallopian tubes. She tried clomid, a medication that stimulates egg production.

At one point, Mike administered twice-a-day injections of gonadotropins, which helped prepare her for ovulation. Pam and Mike each can show you on their fingers the exact length of the needle. She would grit her teeth, but she trusted her husband to help her through. Besides, they wanted a baby that much.

More tests later, they found Mike had a low sperm count.

In the course of the years of treatments, she learned their insurance would pay for a single attempt at in-vitro fertilization. Though the Roman Catholic Church frowns upon in-vitro, they prayed on it and decided to give it a try.

"If we've gone this far, why not try it?" she said.

With a success rate of 16 percent for those older than 40, Pam, a graduate of Chaminade, knows she was one of the lucky ones. That single attempt  using a single embryo  led to the birth of their son, Noah, whom they had baptized in their neighborhood parish.

"We're blessed with him," she said. "He's a miracle baby."

  

Chandra and Dennis Peters

Diagnosis: Secondary infertility.

Happy ending: Now have Emma, 4 months, naturally conceived, as well as 10-year-old Scott.

After their easy first pregnancy, this Nu'uanu couple found themselves venturing into strange territory when they tried for No. 2.

Dennis, an environmental engineer, figured it was stress.

After years of trying and failing, they started fertility tests. Chandra can laugh today about how puzzled the doctors were when the tests would come back. They'd tell her she had a "gorgeous" uterus. "Wonderful" tubes.

But ...

"Every time I'd get my period, I'd be a wreck," she said.

She started taking medications. He had his sperm tested. They went through about five intrauterine inseminations, but never considered adoption: "I was very determined to birth another baby," Chandra said. "With my first-born, the experience was so amazing. ... I'm too selfish. I wanted to have that control of knowing what genes were there."

She became depressed, but then would count her blessings: She was lucky to have one child.

Dennis, oldest of five sons, learned his brothers were having second children. They'd get calls from family, wondering if it was OK to share the good news with them. Of course Chandra was happy for her sisters-in-law, and wanted to take part in their joy, but ... "that night, I'd fall apart," she admits.

After she learned about Resolve, a support group for people with fertility problems, she picked up a packet about in-vitro fertilization, but they decided against that route. Chandra, a Protestant, said she wondered if perhaps it was God's will: "Maybe I'm not meant to have another baby."

Dennis says in is inimitable way: "I think there's a world order to things. I came from a farmer mentality. 'The weather's bad, the crop turns sour.' If you have kids, you have kids. If you don't have kids, you don't have kids."

Nine to 10 months later, about the time it takes to gestate a full pregnancy and just three days before their son's 10th birthday, she learned she was pregnant.

  

Joann and Clarence Sales

Diagnosis: Extreme male factor (quadriplegic), sperm extracted by a urologist and egg fertilized by having a single sperm injected into egg through micromanipulation.

Happy ending: Their baby, Amalya, was delivered in March.

Note: The couple has five frozen embryos and plans to go through implantation again.

Joann met Clarence Sales long after he became wheelchair-bound. He had suffered a fractured cervical vertebrae in a fight when he was 19, but today sees it as a saving moment rather than something to rage against. If it hadn't been for the fight, he might not have turned his life around, and met Joann at the Aloha Assembly of God Church.

Before they married, however, Clarence told her he wasn't sure he could have kids and she was free to walk away. She didn't.

Besides, she had peeked into some of his medical literature and learned that having a child was possible. And for this young Salt Lake mother, "possible" might just as well mean "probable." That's just the kind of woman she is.

They tried to conceive naturally. A work acquaintance at Honolulu Medical Group told her about fertility experts.

They underwent in-vitro procedures. She did five months of injections. He underwent an extraction of sperm, which was then used to fertilize a dozen eggs, some of which didn't survive.

They believe those embryos are life, and if they find they all manage to survive the freezing and thawing process after they've had all the children they intend to have, Clarence and Joann said, they'll put them up for adoption.

Correction: An infertility seminar on "New Procedures in the IVF Laboratory" will be presented at 6:30 p.m. Thursday at Kapi'olani Medical Center. An incorrect title was given for the seminar in a previous version of this story.